Provider Demographics
NPI:1154442952
Name:KEISEL, MARK A (PTA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:KEISEL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 BUCKLER AVE.
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:NC
Mailing Address - Zip Code:28315
Mailing Address - Country:US
Mailing Address - Phone:757-268-1817
Mailing Address - Fax:
Practice Address - Street 1:100 EAST RHODE ISLAND AVE. EXT.
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387
Practice Address - Country:US
Practice Address - Phone:910-692-0371
Practice Address - Fax:910-692-0346
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3793225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant